This invention, in general, relates to a method and system of processing information of members and service providers in the health care industry to improve the quality of health care in a health plan.
Health care organizations perform performance tests on existing health plans to determine the quality of health care provided to the members of a health plan. Increased attention to medical care has resulted in the development of a set of standardized measures that specify how health plans collect, audit, and report performance information across clinical areas, and dimensions significant to customer satisfaction and patient experience. A measure is a medical observation or test performed on a member by a health care provider.
A set of standardized performance measures called the Health Plan Employer Data and Information Set (HEDIS) has been developed and maintained by the National Committee for Quality Assurance (NCQA) to allow consumers to compare performance of a health plan to other plans, for Medicare plans and Medicaid plans, and compare employer groups within a health plan in commercial health plans. The performance of the health plan may also be compared to national HEDIS benchmarks or regional, benchmarks. HEDIS data are collected through surveys, medical charts, insurance claims for hospitalizations, medical office visits, and pharmacies. HEDIS results are used for tracking the year-to-year performance of the health plans.
Health plans report the percentage of members requiring specified HEDIS measures. Health plans may provide for collection of data for these measures by reviewing insurance claims or clinical charts of members. This chart review requires manual intervention by health plan staff to determine whether the members have implemented the measures. Moreover, primary care physicians (PCPs) of a health plan need to follow up with their members to ensure the implementation of the measures. Therefore, there is a need for a computer implemented method and system to reduce the level of review of clinical charts by the health plan staff, and improve the quality of health care in a health plan. Such a computer implemented method would proactively notify PCPs and identified members to facilitate implementation of the predetermined measure and notify the health plan staff to coordinate such implementation, and also provide the PCPs the interface to update an implemented measure. Collectively these two methods would increase the performance score of the predetermined measures and reduce the level of chart review thereby improving healthcare quality.